THE Obstetrics & Gynaecology HO Guide PDF

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THE OBSTETRICS & GYNAECOLOGY HO GUIDECompiled Dr Gerard Loh,Special Thanks Dr Liew Nyan Chin, Dr Rosalina AliDr Murali, Dr Low Wea Haw, Dr Lavitha, Dr Ranjit, Dr Maiza, Dr Shilpa, Dr LizaDr Wong JC, Dr Yusnira, Dr Rosvin, Dr Suri, Dr Komal, Dr Mimi, Dr Che Hasnura,Dr Mashar, Dr Sharmina, Dr ...

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THE OBSTETRICS & GYNAECOLOGY HO GUIDE Compiled Dr Gerard Loh, Special Thanks Dr Liew Nyan Chin, Dr Rosalina Ali Dr Murali, Dr Low Wea Haw, Dr Lavitha, Dr Ranjit, Dr Maiza, Dr Shilpa, Dr Liza Dr Wong JC, Dr Yusnira, Dr Rosvin, Dr Suri, Dr Komal, Dr Mimi, Dr Che Hasnura, Dr Mashar, Dr Sharmina, Dr Bahijah, Dr Fauziah, Dr Saleha and to fellow colleagues , Sisters, SN and JM who taught me so much! CONTENTS 1. Patient Assesment Centre - Obstetrics/Gynae Clerking - Table of common problems - Obstetric Examinations - Cardiotocography - Obstetric Ultrasound 2. Labour Delivery Suite - Partogram - Labour Augmentation - Artificial Rupture of Membrane - Episiotomy and repair 3. Common Ward Problems and Management 4. The Gynae – Onco Ward - Oncology and Chemotherapy

Places of duty Labour Delivery Suite + HDU Patient Assesment Centre Wards – Antenatal, Postnatal, Gynae-Onco, NICU/Paeds OT ELLSCS Mon-Fri, Gynae – Tues,Thurs Clinic

Shift system LDS PAC 4D Antenatal ward 4C Postnatal ward 6A Gynae-Onco ward

Wards 4D / 6A

AM 7am-6pm weekdays 7am-2pm Saturday

PM 11am-11pm weekday 10am-11pm weekend

7am-6pm weekday 7am-11am weekend (Grp in charge of ward)

11am-11pm weekday

7am-2pm Saturday 1 Group will be in charge of wards every 2 weeks *2 HOs goes to clinic

ON 10pm-10am * 2 HOs to clinic next morning on Mon/Wed/Fri 10pm-10am

10am-11pm weekend (4D+4C) (6A) - 10am-2pm (review mothers in 4A+NICU) - 2pm-11pm ( ward)

*both ward HOs to 4C next morning 7am-10am * ward HOs must do night review for 4C

* tends to change from time to time This compilation of short notes is intended only as a quick reference guide. Always refer to your hospital’s own protocol for the full plan and management i.e HA O&G protocol May this guide assist you in your O& G Posting! Special thanks to Dr Liew for assisting me in this project. Your kindness will be remembered by us all. Gerard Loh Chien Siong M.D., CSMU, Ukraine O&G Posting March-June 2012 More: HOW O&G guide part 1 available on www.myhow.wordpress.com

Abbrevations

1. AC‐ abdominal circumference 2. AFI‐ amniotic fluid index 3. AFP‐ Alpha feto protein 4. ACL‐ Anticardiolipin antibody 5. AID‐ artificial insemination of husband’s sperm 6. AID‐ artificial insemination of donor’s sperm 7. ANC‐ antenatal clinic 8. APH‐ antepartum hemorrhage 9. APS‐ antiphospholipid syndrome 10. ARM‐artificial rupture of membrane 11. A&W‐ alive n well 12. ACH‐after coming head 13. BBA‐ born before arrival 14. BOH‐ bad obs history 15. BPD‐ biparietal diameter 16. BPP‐biophysical profile 17. BSO‐ Bilateral salphingoophorectomy 18. BTL‐ bilateral tubal ligation 19. BSP‐ blood sugar profile 20. CCT‐ controlled cord traction 21. CIN‐ cervical intraepithelial neoplasia 22. COCP‐ combined oral contraceptive pills 23. CRL‐ crown rump length 24. CTG‐ cardiotocograph 25. Cx‐ cervix 26. CRN‐cord round neck 27. CEA‐ carcino embryogenic antigen 28. c/o‐ complaint of 29. DD&C‐ diagnostic dilatation n curettage 30. DVT‐ deep vein thrombosis 31. d/w‐ discuss with 32. D&C‐ dilatation and curettage 33. DIVC‐ disseminated intravascular coagulation 34. DUB‐ dysfunctional uterine bleeding 35. DCDA‐dichorionic diamniotic 36. DCMA‐ Dichorionic monoamniotic 37. ECV‐ external cephalic version 38. EDD‐ estimated date of delivery 39. EFW‐ estimated fetus weight 40. EL LSCS‐ elective lower segment C‐section 41. EM LSCS‐ emergency lower segment C‐section 42. ERPOC‐ evacuation of retained products of conception

43. ERT‐ estrogen replacement therapy 44. E2‐ estradiol 45. EUA‐ examination under anaesthesia 46. EBL‐ estimated blood loss 47. FL‐ femur length 48. FKC‐ fetal kick chart 49. FSB‐ fresh still birth 50. FH‐fetal heart 51. FHH‐fetal heart heard 52. FHNH‐ fetal heart not heard 53. FHHR‐ fetal heart heard regular 54. FM‐ fetal movement 55. GDM‐ gestational DM 56. GS‐ gestational sac 57. G‐ gravida 58. GnRH‐ gonadotropin releasing hormone 59. GBS‐ group B streptococcus 60. HC‐ head circumference 61. hCG‐ human chorionic gonadotropin 62. HRT‐ hormone replacement therapy 63. HSG‐ hysterosalphingogram 64. HbA1c‐ glycosylated Hb 65. HVS‐ high vaginal swab 66. Hystrec‐ hysterectomy 67. HGSIL‐high grade squamous intraepithelial lesion 68. HPV‐ human papilloma virus 69. h/o‐ history of 70. IE‐ impending eclampsia 71. IGT‐ impaired glucose tolerance 72. IOL‐ induction of labour 73. ISD‐ interspinous diameter 74. ITD‐ intertuberous diameter 75. IUCD‐ intrauterine contraceptive device 76. IUI‐ intrauterine insemination 77. IUD‐intrauterine death 78. IUGS‐ intraunterine gestational sac 79. IUGR‐ intrauterine growth restriction 80. I&D‐ incision and drainage 81. Ix‐ investigation 82. IVF‐ in vitro fertilization 83. KIV‐keep in view 84. KK‐ klinik kesihatan 85. LA‐ lupus anticoagulant

86. Lap & Dye‐ laparascopy and dye insufflation 87. LAVH‐ Laparascopic assisted vaginal hysterectomy 88. LMSL‐ light meconium stained liquor 89. LNMP‐ last normal menstrual period 90. LPC‐ labour progress chart 91. LOA‐ left occipito anterior 92. LOP‐ left occipito posterior 93. LOT‐ left occipito transverse 94. LH‐ luteinizing hormone 95. LBW‐ low birth weight 96. LGSIL‐ low grade squamous intraepithelial lesion 97. MA‐ membrane absent 98. MOGTT‐ modified oral glucose tolerance test 99. MI‐ membrane intact 100. MMSL‐ moderately meconium stained liquor 101. MOD‐ mode of delivery 102. MMG‐ mammogram 103. MRP‐ manual removal of placenta 104. MSB‐ macerated stillbirth 105. OCP‐ oral contraceptive pills 106. OA‐ occipito anterior 107. OP‐ occipito posterior 108. OT‐ occipito transverse 109. OI‐ ovulation induction 110. o/e‐ on examination 111. PA‐ placenta abruptio 112. PCOS‐ polycystic ovarian syndrome 113. PE‐ pre‐eclampsia/ pulmonary embolism 114. PE chart‐ pre‐eclampsia chart 115. PFR‐ pelvic floor repair 116. PID‐ pelvic inflammatory disease 117. PIH‐ pregnancy induced hypertension 118. PNC‐ postnatal clinic 119. POA‐ period of amenorrhea 120. POC‐ product of conception 121. POD‐ pouch of Douglas 122. PMB‐ postmenopausal bleeding 123. POG‐ period of gestation 124. POP‐ progesterone only pills 125. PP‐ placenta previa 126. PPH‐ postpartum hemorrhage 127. PROM‐ premature/prelabour rupture of

membrane 128. PPROM‐ preterm premature/prelabour rupture of membrane 129. PV‐ per vaginal 130. P/A‐ per abdomen 131. P‐ para 132. REDD‐ revised expected date of delivery 133. ROA‐ right occipito anterior 134. ROP‐ right occipito posterior 135. ROT‐ right occipito transverse 136. Re‐ review 137. RPC‐ retro‐placental clot 138. S&C‐ suction and curettage 139. SE‐ speculum examination 140. SFH‐ symphysiofundal height 141. SGA‐ small for gestational age 142. SPA‐ suprapubic angle 143. SROM‐ spontaneous rupture of membrane 144. St‐ station 145. SVD‐ spontaneous vertex delivery 146. SOD‐ sure of date 147. s/b‐ seen by 148. STO‐ suture to open 149. SCC‐ squamous cell carcinoma 150. STD‐ sexually transmitted disease 151. STI‐ sexually transmitted infection 152. Synto‐ syntocinon 153. TAHBSO‐ total abdominal hysterectomy with bilateral salphingoophorectomy 154. TAS‐ transabdominal scan 155. TCA‐ to come again 156. TLH‐ total laparascopic hysterectomy 157. TOS‐ trial of scar 158. TOP‐ termination of pregnancy 159. TVS‐ transvaginal scan 160. TMSL‐ thick meconium stained liquor 161. UV prolapsed‐ uterovaginal prolapse 162. Ut‐ uterus (Ut‐TS: uterus at term size) 163. UPT‐ urine pregnancy test 164. USOD‐ unsure of date 165. VBAC‐ vaginal birth after Caesarean 166. VE‐ vaginal examination 167. V/v‐ vulva/vagina 168. Vx‐ vertex

PAC (Patient Assessment Centre) s/b or d/w ___ (Medical officer/specialist) Obstetrics Clerking Age/Race: Gravidity, parity (G1P0) @ Gestation age: @ weeks + days by POA/POG/REDD Dates: SOD/USOD, Menses: previously regular/irregular menses, Contraception: IUCD/barier/OCP?

1st Trimester 1-12 2nd Trimester 13-27 3rd Trimester 28-42 Term = 37- 40 weeks Preterm = 1 weeks discrepancy, REDD shld be given if REDD was given earlier, use it to calculate POG Marital status: SMS/2nd union Conception- spontaneous/ artificial/subfertility ANC: (PIH/PE/GDM/ANEMIA/UTI/URTI/Candidiosis / history of abortion..etc) or uneventful c/o or referred from KK/GP for…. Otherwise no show, no LL, no UTI, no fever, no contraction pain good FM

Early pregnancy problem: (check antenatal book – pink book) -booking date @ weeks, @ KKIA _____ -booking BP__ , remains normotensive throughout pregnancy ranging ___ -Booking Hb__ , anemic? Latest Hb__ -MGTT done? (indication: family hx, age >35, excessive weight gain, prev macrosomia/GDM/fetal abnormalities) -Albuminuria/glycosuria? -Blood Group / Rhesus (if NEGATIVE, any Rhogum given, @ __weeks -Infections screening done? (VDRL/HIV screening) Not reactive Past Obstetric hx: year, mode of delivery, hospital, baby sex, weight , any complications? * if spacing >5years- why? Voluntary? Diff union? * Pay attention to prev scar, indication of LSCS, counselling for VBAC *post partum: fever/prolonged stay in ward/ wound breakdown/PPH/blood transfusion? Medical/surgical history - known medical illness or surgeries ( asthma, thyroidism, DM, HPT etc) Social Hx: marital status (married/SMS/2nd union), occupation, husband’s occupation, smoker/alcohol, type of house/rented/own resident Clinical Assesment General: alert, conscious, not pale, non tachypnoic, hydration fair Systemic: lungs clear, CVS DRNM, Thyroid NAD (goiter), Breasts NAD (cyst/engorged/mass) Pa: soft, non-tender, singleton, uterus @wks, cephalic ?/5, EFW, scars? Speculum: (if indicated: LL, PV bleed/prem cx) Cervix healthy (ectropion/fibroid), cough test +/- Litmus test, pooling of liquor, os closed, * any discharge (white curdy/pus)- take High Vaginal Swab (Mandatory if pt is subjected to speculum) Ve: VV normal (varicosity, vesicles,cysts..etc) , Os dilation, Cervix effacement, Station, Vertex, membrane intact/absent, no cord/placenta u/s: Presentation, Lie, Placenta Site, AFI, EFW, CGA , parameters – BPD, FL, AC, HC CTG: Define risks, Contractions, Baseline Fetal Heart Rate, Variability, Acceleration, Deceleration (refer to CTG section) Impression: summary of problem (25 yo malay lady, G1P0 @ 38 weeks, Imp: active phase of labour)

Management:

Common problems, assessment and management C/O Lower abd pain - intensity -frequency a/w show/LL? Leaking liquor -since @ time - hx/clinic suggestive? - character, density (Clear?) - gushing/dribbling/?urine - soak pants/spots - used pads? Show - @ time - mucous+blood a/w abd pain? - a/w leaking liquor? - pad soaked/spotty PV bleed - @ time, a/w pain? - spotty/stain/soaked - trauma? Any POC - scans/placenta Discharge - colour, smell - amount, using pad? - -dysuria, itchy, fever? - ? LL UTI symptoms - dysuria, burning - frequent urgency -fever Reduced FM - correct FKC? 9am-9pm - usual time of completion - ANC prob? h/o trauma? - h/o UTI/candida? High BP - 1st episode @ wk - on Rx? - h/o hyptertn prev pregnancy - signs of IE Blurring of vision, headache, giddiness, epigastric pain, reflexes brisk, clonus GDM - dx @ wks - diet control/insulin - latest MGTT/BSP - EFW, last scan Prem contraction - @ wks - frequency - h/o UTI/candida? - dexa given? Anemia - Hb @ wks, latest - on hematinics/obimin - hx transfusion? Rhesus Negative - Gravidity/parity - husband/prev baby Rh Thyroidism - dx @ wks - hypo/hyperthyroidism - on medication?

Clinical assessment 1) PA 2) VE 3) CTG 1) PA 2) Speculum + HVS 3) VE 4) CTG 5) Scan – AFI

* Primid Os closed/TOF/< 3cm = allow home if nearby+ transport available *>3cm = for admission Ddx = stones, appendicitis, AGE * if hx and clinically demonstrablePPROM/PROM? * if not Hx suggestive, clinically not demonstrable, admit for pad chart| Start antibx after 18hrs, if not delivered, KIV IOL if >24hrs w/o for signs of chorioamnionitis – fetal and maternal tachycardia, fever, meconium, WCC elevated

1)PA 2) speculum/VE 3)CTG

* Primid Os closed/TOF/< 3cm = allow home if nearby+ transport available *>3cm = for delivery Ddx = PV bleeding

1) PA 2) Speculum 3) CTG (>34/52)

* > 22weeks TRO Placenta praevia / acreta (detailed scan) * < 22weeks TRO miscarriage * if indeterminate APH, do not allow post dates Ddx = cervical ectropion

1) PA 2) speculum + HVS 3) UFEME

Curdy white = vaginal candidiasis. Treat with canestan pessary I/I ON

1) UFEME (Leu/nitrate +) 2) Urine C & S

Start antibiotics (T. Cephalexin 500mg TDS 1/52) ural I/I sachet tds 3/7

1) PA 2) scan FH/FM 3) CTG (>34/52)

Observe 1 day FKC in ward (case to case basis) Teach correct method of recording FKC if persistently reduced and at term, consider IOL

Repeat BP manual if >140 Adalat 10mg stat then, monitor BP ¼hrly Admit for BP monitoring Daily urine albumin 24hr Urine protein UFEME PE profile MGTT/BSP Scan plot growth chart HbA1C(?Preexisting DM)

BP monitoring in ward PIH – Hypertension in previously normotensive mother PE – Edema + Proteinuria + Hypertension w/o signs of IE – blurring of vision, brisk reflexes, clonus, edema, proteinuria Eclampsia – EPH + tonic/clonic seizures

Scan Time contraction CTG

If poor diet control, 7 point BSP KIV insulin if deranged Do not allow post date detailed scan for fetal abnormalities/macrosomia opthalmo appointment refer dietician < 34weeks, consider tocolysis 34-37weeks, allow labour if progress (d/w MO) IM Dexamethasone 12mg x 2 doses 12 hrs apart T. EES 400mg tds for 5/7

1) anemic signs 2) FBC (Hb/MCH/MCV) 3) Anemic profile (Fe) 4) scan 5) * FBP/Hb Analysis 1) GSH 2) Coombs test

Scan for fetal abnormalities Determine type of anemia (IDA, B12/Folate deff/thalasemia etc)

1) thyroidism signs 2) TFT

Hypo = L-Thyroxine Hyper – PTU Carbimazole after d/w endocrinologist(under combine clinic every last Thursday of the month)

* Rhogam at 28wks and 34weeks, and within 72hrs post partum

The Antenatal Book (pink book) from KKIA

STICKERS Under the WHITE code: (case suitable for home delivery - provided trained birth attendant is present) 1. 2. 3. 4. 5.

Gravida 2-5 No previous obstetric problems No medical conditions like anemia, hypertension, Diabetes, heart diseases, Tuberculosis, Asthma. No complications in the present pregnancy Cephalic presentation

Under the GREEN code: (Refer cases to public health nurses) 1. 2. 3. 4. 5. 6.

Maternal age: Primigravida: 35 years old and Multipara: 40 years old and above Gravida 6 and above Birth interval of less than 2 years or above 7 years Mothers with special problems, e.g. psychiatric, handicapped, single parent Height Unsure of dates

Under the YELLOW code: (Refer to doctor at healthcare centre or hospital) 1. 2. 3. 4. 5. 6. 7. 8.

Rhesus negative Hb Dyspnea on exertion Urine albumin 1+ Multiple pregnancy Decreased fetal movement Obesity >80kg Drug addiction

Under the RED code: (Immediate hospital admission) 1. 2. 3. 4. 5. 6. 7.

Severe pre-eclampsia Eclampsia Antepartum haemorrhage preterm labour Meconium stained liquor Cord prolapse Retained placenta

Management of common problems In Active Phase Of Labor Transfer to LDS -plot partogram - VE on strong contraction /bearing down - Time contraction in 2hrs, if suboptimal for augmentation as per protocol - IVD 4pints HM/24hrs Con’t central CTG monitoring with 2hrly intermittent tracing offer entonox IM pethidine 75mg + IM phernegan 25mg if CTG reactive Latent phase of labour admit ward 4D CTG daily FKC LPC/ FHR 4hrly VE on Strong contraction/ bearing down/ or LL FBC, GSH **************************************************** PROM/Leaking Liqour admit ward 4D -FBC / GSH / HVS -LPC / FHR 4hrly -strict FKC -CTG daily -strict pad chart - to inform if greenish discharge -watchout for s/s of chorioamnionitis -start IV ampicillin 2g stat, if not delivered after 18hr @ __H, then 1g QID -KIV IOL if not delivered after 24hr * if allergic to penicillin - clindamycin ************************************** Reduced FM admit ward 4D FBC / GSH LPC / FHR 4hrly strict FKC CTG daily if persistently reduced FM, KIV IOL ************************************** Premature contraction for tocolysis admit HDW FBC / GSH / HVS / UFEME LPC / FHR 4hrly strict FKC T. adalat 20mg in 4 doses every 15mins IM dexa 12mg stat then 12hr later book ventilator ************************************** False labour Allow home with reassurance TCA stat if abdominal pain/LL/PV bleed/foul smelling discharge TCA at EDD +9/7 for IOL if not yet delivered * GDM/PIH/PE/Indeterminate APH cannot allow post dates ************************************** Vaginal Candidiosis Allow discharge with medication Canesten pessary 500mg ON 1/7 TCA 2/52 clinic to review HVS TCA stat if abdominal pain/fever/foul smelling discharge/PB bleed UTI

Allow discharge with medication HVS/UFEME/Urine C&S taken-to trace T.Cephalexin 500mg tds x 1/52 Sachet Ural 1/1 TDS x3

Gynae Clerking (pregnancy flow than usual menses? - heavy physical activity prior to onset? - How many pads used? - recent SI? - a/w abd pain? - passed out any POC? Clots or fresh blood

Vital signs w/o hypovolemic shock FBC/GSH Sexually active  UPT/ Beta HCG

Abdominal Pain/discomfort - pregnant?UPT done self/GP +? - onset time, history, contraceptives? - location of pain, radiating?contraction? - anemic sx? Fainting?giddiness? - a/w PV bleed? - a/w dysuria?PV discharge? - abdominal distension? Mass?

Vital signs w/o hypovolemic shock FBC/GSH Sexually active  UPT/beta HCG PA: mass? Guarding? U/S ectopic: free fluid POD, empty Ut, ET thick fibroids/ca/cyst = unusual mass IUD= no FH/FM UTI= suprapubic pain, itchy, dysuria CT TAP results HPE results

Miscarriage/ectopic/molar/IUD Ovarian cyst/ cancer

Ca markers CA125, CEA etc. Beta HCG/AFP - PTB

Prechemo/pre op Blood Ix Digitalize CT scans

UFEME: Ket +, Nitrite+ RP :dehydrated picture Loss of weight

IVD 6 pints HM Daily urine ketone Vomit chart, I/O chart IV Maxolon 10mg tds IV ranitidine 50mg tds Hyperemesis advice

Oncology cases - first presentation, hospital, symptoms - PAP smear/sampling done? - early and latest scans – CT TAP/MRI - surgeries – TAHBSO/TLH/cystectomy etc? - HPE results - chemo/radiotherapy done? - agent, line, cycle ? Hyperemesis gravidarum - onset, how many times per day - ate outside?food poisoning? - fever? Chills? Rigor? - LOA, poor oral intake - LOW? - a/w diarrhoea/abdominal pain? - character: food/bile/blood/projectile? GDM (25mm / TVS >20mm 4) Molar pregnancy - no fetal pole- only vesicles - snowstorm appearance - Beta HCG 5) TRO ectopic pregnancy - empty uterus - presence of adnexal mass with free fluid - take beta HCG

Per Speculum U/S TRO ectopic/miscarriage/fibroids/tumour PAP smear TRO Ca VE: Os open/closed

DDx: nausea and vomiting in pregnancy, AGE, food poisoning, gastritis/GERD

HbA1C – to determine new or preexisting MGTT

Miscarriage- observe, D&C/ERPOC ectopic - diagnostic lap Ectropion/Polyps/ molar pregnancy Fibroids – surgery/hormonal Endometriosis –review PAP smear Cervix Ca - onco clinic Menorrhagia/dysmenorrhea- hormone, clinic Threathened miscarriage – TCA 2/52 for U/S or TCA stat if POC passed out, bring POC

Ddx: gastritis, appendicitis, renal colic, cholelithiasis/cystitis/UTI Admit for surgery

Surgery/chemo/radiotherapy Admit for op/TCA onco clinic for counselling

4 or 7 pt BSP refer dietician ophthalmo appt Detailed scan appt

Per abdomen examination 1. soft non tender 2. Uterus @ __ weeks (SFH)

3) singleton, cephalic /5 (how many fingers in relation to symphysis pubis) 4-5/5 = ballotable/not engaged, 30-45mins - Retained placenta

Inform Peds - EMLSCS (reason, gestational age, EFW) - Thick meconium - Instrumental deliveries - SGA/Macrosomic/Fetal abnormalities - GDM on insulin

Plot Partogram

Time contraction, if subopti...